Type of Encounter

History

HPI

History of Present Illness - Characterize HPI by considering EITHER the status of 3 chronic or inactive conditions OR the number of elements recorded.

No HPI

3 Chronic or Inactive Conditions

Elements

Result: N/A

ROS

Review of Systems - Check all systems that are represented in the documentation:

Constitutional Allergy/Immunology Gastrointestinal Integumentary (Skin) Eyes Genitourinary Ears, Nose, Mouth, Throat Hematologic/Lymphatic

Respiratory Endocrine Neurologic Musculoskeletal Cardiovascular Psychiatric All other systems were negative

Result: N/A

PFSH

Past, Family, and Social History

Past history The patient's past experiences with illnesses, hospitalizations, operations, injuries, treatments, medications, immunizations, allergies, feeding issues, etc. where related to current CC, HPI, ROS. Family history A review of medical events in the patient's family, including diseases that may be hereditary or place the patient at risk; genetic conditions, health status/deaths of parents, siblings, etc. where related to current CC, HPI, ROS. Social history An age appropriate review of past and current activities; marital status, tobacco/alcohol/drug use, employment, military status, legal issues, sexual history, living arrangements, etc. where related to current CC, HPI, ROS.

Result: N/A

History Result

N/A
The result is based on the lowest level of service performed:

History Component	Problem Focused (PF)	Expanded (EPF)	Detailed (D)	Comprehensive (C)
HPI	Brief (1-3 elements)	Brief (1-3 elements)	Extended (4+ elements)	Extended (4+ elements)
ROS	N/A	Problem Pertinent (1 system)	Extended (2-9 systems)	Complete (10+ systems)
PFSH	N/A	N/A	Pertinent (1-2 areas)	Complete (3 areas)
Level	99201	99202	99203	99204/99205

Examination

Calculate number of body areas, organ systems, or bullet points... (click here)

Select the exam level. Select for both 95 and 97 Guidelines. Or use the calculator above.

Type of Exam	95 Guidelines	97 Guidelines - General Multi-system	97 Guidelines - Cardiovascular	Level
None	N/A	N/A	N/A	N/A
Problem Focused (PF)	1 Body Area or Organ System	1-5 bulleted elements	1-5 bulleted elements	99201
Expanded Problem Focused (EPF)	2-7 Body Areas or Organ Systems (or 4x4)	6-11 bulleted elements	6-11 bulleted elements	99202
Detailed (D)	2-7 Body Areas or Organ Systems with affected system in detail	12-17 bulleted elements for 2+ systems	12-26 bulleted elements	99203
Comprehensive (C)	8 Body Areas or Organ Systems	18+ bulleted elements for 9+ systems (see requirements for individual single system exams)	All bulleted elements	99204/99205

Medical Decision Making (MDM)

Number of Diagnosis or Treatment Options

Problem(s) Status	Number	*	Points	=
Self-limited or minor (stable, improved, or worsening)	(max 2)	*	1	=
Established problem (to examiner) (stable, improved)		*	1	=
Established problem (to examiner) (worsening)		*	2	=
New problem (to examiner); requiring no additional workup to assess a diagnosis	(max 1)	*	3	=
New problem (to examiner); requiring additional workup to assess a diagnosis		*	4	=
Result: N/A

Amount and/or Complexity of Data Reviewed

Reviewed Data
Review and/or order of clinical lab tests	1
Review and/or order tests in the radiology section of CPT^®	1
Review and/or order tests in the medicine section of CPT^®	1
Discussion of test results with performing physician	1
Decision to obtain old records and/or obtain history from someone other than patient	1
Review and summarization of old records and/or obtaining history from someone other than patient and/or discussion of case with another health care provider	2
Independent visualization of image, tracing or specimen itself (not simply review of report)	2
Result: Minimal	0

Risk of Complications and/or Morbidity or Mortality

Level	Presenting Problem(s)	Diagnostic Procedure(s) Ordered	Management Options
Minimal	One self-limited or minor problem, e.g., cold, insect bite, Tinea Corporis	Lab tests requiring venipuncture Chest x-rays EKG/EEG Urinalysis Ultrasound, e.g., echo KOH prep	Rest Gargles Elastic bandages Superficial dressings
Low	Two or more self-limited or minor problems One stable chronic illness, e.g., well-controlled hypertension or non-insulin dependent diabetes, cataract BPH Acute uncomplicated illness or injury, e.g., cystitis, allergic rhinitis, simple sprain	Physiologic tests not under stress, e.g., pulmonary function tests Non-cardiovascular imaging studies with contrast, e.g., barium enema Superficial needle, biopsies Clinical laboratory tests requiring arterial puncture Skin biopsies	Over-the-counter drugs Minor surgery with no identified risk factors Physical therapy Occupational therapy IV fluids
Moderate	One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment Two or more stable chronic illnesses Undiagnosed new problem with uncertain prognosis, e.g., lump in breast Acute illness with systematic symptoms, e.g., pyelonephritis Acute complicated injury, e.g., head injury with brief loss of consciousness	Physiologic tests not under stress, e.g., cardiac stress test, fetal contraction stress test Diagnostic endoscopes with no identified factors Deep needle or incisional biopsy Cardiovascular imaging studies with contrast and no identified reisk factors, e.g., arteriogram cardiac cath Obtain fluid from body cavity, e.g., lumbar puncture, thoracentesis, culdecentisis	Minor surgery with identified risk factors Major surgery (open, percutaneous or endoscopic) with no identified risk factors Prescription drug management Therapeutic nuclear medicine IV fluids with additives Closed treatment of fracture or dislocation without manipulation
High	One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment Acute or chronic illnesses or injuries that may pose a threat to life or bodily function, e.g., multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure An abrupt change in neurologic status, e.g., seizure, TIA, weakness or sensory loss	Cardiovascular imaging studies with contrast with identified risk factors Cardiac electrophysiological tests Diagnostic endoscopies with identified risk factors Discography	Major surgery (open, percutaneous or endoscopic) with identified risk factors Emergency major surgery (open, percutaneious or endoscopic) Parenternal controlled substances Drug therapy requiring intensive monitoring for toxicity Decision not to resuscitate or de-escalate care because of poor prognosis
Result: N/A

MDM Result

MDM Complexity	Straight Forward	Low	Moderate	High
MDM Complexity is based on the 2nd lowest of the components.
# of Dx/Tx options	Minimal (1)	Limited (2)	Multiple (3)	Extensive (4)
Amount & complexity of data	Minimal (0-1)	Limited (2)	Multiple (3)	Extensive (4)
Risk	Minimal	Low	Moderate	High

Level of Service

Level	99201 Level I	99202 Level II	99203 Level III	99204 Level IV	99205 Level V
Level of Service is based on the lowest of the components.
History	Problem Focused (PF)	Expanded (EPF)	Detailed (D)	Comprehensive (C)	Comprehensive (C)
Examination	Problem Focused (PF)	Expanded (EPF)	Detailed (D)	Comprehensive (C)	Comprehensive (C)
MDM Complexity	Straight Forward	Straight Forward	Low	Moderate	High

Component-based Level of Service: N/A

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95 Guidelines

97 Guidelines - General Multi-system exam

97 Guidelines - Single Organ Systems Exam